Acute coalescent mastoiditisis a rare
infection of the mastoid
bony process (the bone behind the ear). It is a severe infection which can spread to the brain causing
disability or death. It is usually caused by Streptococcal Pneumonia.
This bacteria is becoming more and more resistant to antibiotics. The
mechanism of penicillin resistance in this organism is by
producing a penicillin binding protein and not by producing penicillinase (an
enzyme which breaks down penicillin). Thus, this organism will also be
resistant to Amoxcillin/Clavulanate and Amoxcillin/Sulbactam.
The
bacterial resistance is transmitted on a plasmid between the bacteria.
A single plasmid can carry the genes for resistance to both the penicillin
and macrolide
antibiotics.

Before the era of antibiotics, this disease was very common and the
treatment was with surgery. A mastoidectomyoperation was routine and was
one of the most frequent operations at medical centers. With the
advent of antibiotics, the cases of acute coalescent mastoiditisdeclined dramatically.
However, when it occurred a complete mastoidectomywas performed. With the
newer stronger generation of antibiotics this disease was treated with a
wide myringotomy( surgically creating a large
hole in the eardrum ) and IV antibiotics, reserving mastoidectomyfor those cases with a cholesteatoma,
intracranial complications, vertigo, facial weakness or a sub-periosteal
abscess. Several articles have reported successful treatments
with the local drainage of the subperiosteal abscess, IV antibiotics and a
wide myringotomy,
and NOT initially performing a mastoidectomy.
View AbstractView AbstractView Abstract

MRI (Magnetic Resonance Imaging) scans
may detect a fluid signal in the mastoid sinus on T2 studies. This
is often described as "mastoiditis" by the radiologist.
However, in the absence of pain, fever and an abnormal ear exam this
finding should not considered diagnostic of mastoiditis and is usually
considered a normal variant. View Abstract

The case presented below is a child which developed acute coalescent mastoiditiswith a sub-periosteal
abscess. Almost all cases develop from patient non-compliance or an
untreated acute otitis media.
The child had been treated with multiple antibiotics including Augmentin ( Amoxcillin / Clavulanate
), none of which eradicated the infection.
Bacterial resistance was suspected and it was elected to perform complete
surgical drainage by performing a mastoidectomy.

Preoperative
Appearance of the Child. Note the protrusion of the
auriclefrom a
sub-periosteal abscess. The abscess at the time of surgery was
found to contain 6 cc of pus and had direct communication with the
mastoidair cells through a small bony dehiscence.

During
the operation, the mastoid cortexwas removed, exposing a large area of
coalescent air cells.

A
complete mastoidectomywas performed. Most of the bone was
osteotic and soft, allowing removal with a curette. Other areas
had to be removed with a drill. A Penrose drain was placed and the
patient was started on IV Antibiotics, Vancomycin and Cefuroximine.
(The picture to the right is taken at 1/2 the magnification of the above
picture. The black outlined area represents the area of initial
bone removal shown in the picture above.)

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